Healthcare Provider Details

I. General information

NPI: 1487931184
Provider Name (Legal Business Name): RAYMOND RENE LUCIO CANDA RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

IV. Provider business mailing address

6301 UNIVERSITY COMMONS SUITE 403
SOUTH BEND IN
46635-1571
US

V. Phone/Fax

Practice location:
  • Phone: 574-334-7410
  • Fax:
Mailing address:
  • Phone: 574-968-2851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number02179
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05005612A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: